Care Home: Greys Residential Home Ltd

What the care home does well The staff work hard to ensure that residents` needs are appropriately assessed and that their care is planned to ensure that these needs are met, whilst encouraging and enabling residents to maintain their independence where possible.The home have a strong commitment to staff training with staff qualification to National Vocational Level 2 in care exceeding the required national minimum standard. Residents spoken with told the inspector how they were happy living at the home and all said that they felt safe living there. One resident spoken with said that all the staff were very caring and helpful and another added that the staff are very kind. One health care professional commented that the home has a `good friendly family atmosphere where all staff are kind and keen to help, nothing being too difficult.` All interactions observed between the management, staff and residents evidenced that the home has a close and caring staff team. One member of staff commented that `all the staff are very kind and friendly. Any problems we may have are solved by the owners.` What has improved since the last inspection? The ongoing maintenance, redecoration and refurbishment programme provides residents with a comfortable and homely environment in which to live. Previous environmental requirements have been met, the home now have a planned maintenance programme in place and repairs have been made to areas identified at the last inspection. Staff recruitment has been reviewed and robust recruitment procedures are now followed for all new staff. All requirements and recommendations made at the last inspection have been met. What the care home could do better: There were no requirements made at this inspection. Recommendations have been made that staff relate their daily records more closely to the required actions set out in the residents` care plans; that newly identified problems are added to the front section of the care plan and that the home explore and introduce more in depth risk assessments, especially for the reduction of falls and the use of bed rails. CARE HOMES FOR OLDER PEOPLE Greys Residential Home Ltd Hook Heath Road Woking Surrey GU22 0JQ Lead Inspector Denise Debieux Unannounced Inspection 1st February 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greys Residential Home Ltd Address Hook Heath Road Woking Surrey GU22 0JQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01483 771523 01483 771523 steve@greysresidential.co.uk Greys Residential Home Limited Mr Stephen Phillip Kennedy Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 2006 Brief Description of the Service: Greys Residential Home Ltd is located in a quiet residential road in Woking. It is family owned and managed and is registered for 20 older people. Accommodation is on two floors and each resident has either en-suite or private facilities adjacent to their rooms. On the ground floor there is a large lounge with a period fireplace, and the main dining room. Upstairs there is also a small lounge/dining area. There is a lift for the convenience of residents. The gardens are very well kept and contain several outdoor seating areas around the home. The main garden has a covered fishpond and rockery, giving a central focus for residents to enjoy. There is car parking space in the drive and on the road. The current scale of charges as at February 2008 is from £500 to £575 per week. There are additional charges for hairdressing, chiropody, newspapers and personal items. Staff escorts to medical appointments etc. are charged at £10 per hour. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This unannounced visit formed part of a ‘key’ inspection and was carried out by Denise Débieux, Regulation Inspector. The Registered Manager was present as the representative for the establishment. It was a thorough look at how well the service is doing. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection. Service users at this home prefer to be referred to as ‘residents’ so this term is used throughout this report. A tour of the premises took place. On the day of this visit the inspector spoke with eight of the twenty residents and four on-duty staff. Prior to the inspection, survey forms were sent to residents, their relatives and/or advocates and to staff employed at the home, survey forms were also available during the inspection. Survey forms were returned by seven residents, six members of staff and three relatives/advocates. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed an annual quality assurance assessment (AQAA) and residents’ care plans, staff recruitment and training records, menus, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector would like to thank the residents and staff for their time, assistance and hospitality during this visit and the residents, relatives and staff who participated in the surveys. What the service does well: The staff work hard to ensure that residents’ needs are appropriately assessed and that their care is planned to ensure that these needs are met, whilst encouraging and enabling residents to maintain their independence where possible. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 6 The home have a strong commitment to staff training with staff qualification to National Vocational Level 2 in care exceeding the required national minimum standard. Residents spoken with told the inspector how they were happy living at the home and all said that they felt safe living there. One resident spoken with said that all the staff were very caring and helpful and another added that the staff are very kind. One health care professional commented that the home has a ‘good friendly family atmosphere where all staff are kind and keen to help, nothing being too difficult.’ All interactions observed between the management, staff and residents evidenced that the home has a close and caring staff team. One member of staff commented that ‘all the staff are very kind and friendly. Any problems we may have are solved by the owners.’ What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the resident’s identified needs. This home does not offer intermediate care. EVIDENCE: In their AQAA, to demonstrate what the home does well, the manager stated that ‘individuals are supported and encouraged to be involved in the assessment process. Information is gathered from a range of sources including other relevant professionals, and with the individual’s agreement. No resident moves into the home without having his/her needs fully assessed, we would firstly visit the resident or ask them to visit us perhaps for an afternoon, we would obtain external advice i.e., from a GP or staff nurse as to the suitability prior to admission, this is noted on the pre admission form, or care managers would supply a copy of their care management assessment. Each Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 9 resident has a full pre admission questionnaire completed by a senior member of our staff.’ Four care plans were sampled during this visit. In each case comprehensive pre-admission assessments had been carried out to ensure that the home could meet the residents’ identified needs. Residents surveyed all felt they had received enough information prior to moving to the home. Data provided in the home’s AQAA does not identify any residents with specific religious, racial or cultural needs at this time. One resident, with family living abroad, is enabled to maintain contact via the laptop computer and internet link provided by the home. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to meet the needs of individuals of various religious, racial or cultural needs. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned is provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: The home has a small and close care team and the staff demonstrate an in depth knowledge of each individual residents’ needs, abilities and preferences in how they wish their care to be delivered, resulting in six of the seven residents surveyed stating that they always receive the care and support they need and one answering ‘usually’. One resident commented that the staff are very caring and helpful. The care plans sampled during this visit were all based on pre-admission assessments and had been drawn up shortly after each resident’s admission to the home and included risk assessments. These care plans set out the actions which need to be taken by care staff to meet the health, personal and social care needs of the residents. Care plans are reviewed on a monthly basis and daily notes are kept that reflect the care given. These daily notes Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 11 demonstrated that any changes or new concerns are promptly acted upon, although not always added to the care plan section of the documentation. This was discussed with the manager and the staff member who oversees care planning and a recommendation has been made that staff relate their daily recording more directly to the actions set out in each care plan and that new problems are added to the front section of the care plan so that they are easy for staff to find. Risk assessments were in place for all identified risks and routinely included risk of falls, skin breakdown and nutrition for all residents. Where a risk had been identified it was seen in the care plans that action had been taken to reduce the identified risk. However, a recommendation has been made that the home look to developing more in depth risk assessments, especially for the risk of falls and the use of bed rails, which were seen to be relatively basic. The home was given information regarding a recent Medical Device Agency alert relating to the use of bedrails; this alert includes instructions for carrying out a detailed risk assessment where the use of bed rails is being considered. Methods of detecting an increasing risk of falls were discussed and the manager plans to liaise with the local falls prevention clinic and develop a falls prevention strategy for the home. All care plans sampled had been signed by the residents or their representative to signify their involvement and agreement. The lunchtime medication round was observed and the medication administration records (MAR sheets), medication storage, policies and procedures were all sampled and found to be in order. However, the audit trail for the receipt, administration and disposal of controlled drugs was difficult to follow and initially it appeared that there were some discrepancies in the tallies. However, before the end of the inspection the assistant manager had carried out a full audit and was able to demonstrate that the stock tallied with the amounts received, administered and disposed of. There was also an administrative error where the name of the resident had been entered in the place where the name of the drug should be in the controlled drug register, despite this the staff had continued to sign and witness the register and none had picked up the error. The MAR sheet for this person however was correct. In order to prevent a recurrence of these errors the manager stated that he will arrange for the local pharmacist to come to the home and carry out a full medication audit, has obtained a copy of the new guidance from the Royal Pharmaceutical Society on the handling of medications in care homes, will ensure all staff responsible for handling medication read and understand the guidance plus the manager will carry out follow up supervision with all staff to ensure the correct procedures for handling medications are followed. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 12 In their AQAA, to demonstrate what the home does well, the manager stated that ‘Every resident has an occupational therapy assessment within 7 days of occupation. Aids and equipment are provided to encourage maximum independence for people using the service; these are regularly reviewed and replaced to accommodate changing needs, most recently walk in baths for all bathrooms. The home arranges for health professionals to visit residents at home when necessary. The home strongly promotes independence and those individuals, assessed as being able, are encouraged and supported to manage their own medication.’ During the tour of the home staff were observed to always knock before entering the residents’ bedrooms and all interactions observed between staff and residents were seen to be caring and respectful. All residents surveyed and spoken with said that they felt their privacy was always respected. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provided by the home are individualised to each resident and include contact with the local community both within and outside the home. Contacts with family and friends are encouraged. Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: The routines of daily living are arranged to suit individual resident’s preferences and choices. This was confirmed by residents spoken with. The activity programme for February was seen at this visit. Activities provided included: a weekly exercise to music group; flower arranging; weekly movies; board games; card games and baking afternoons. Six of the seven residents surveyed stated that there were always activities they could participate in, with one answering ‘usually’. On the day of this inspection the weekly exercise to music session took place. The session was well attended and residents spoken with after the group expressed their enjoyment. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 14 Residents are able to choose which activities they attend or participate in and their individual rooms were all seen to contain many personal possessions, which were arranged to suit their individual wishes. There are no restrictions to visiting times and staff support and encourage residents to maintain family links and friendships inside and outside the home. Menus sampled showed that the home offers a varied and well-balanced menu, with residents able to choose alternatives if they do not want the dish that is on the menu on the day. The lunchtime meal was taking place during this visit, the food was well presented, the atmosphere in the dining room was pleasant and relaxed and there were ample staff available to offer help and assistance as needed. Of the seven residents surveyed, three said that they always liked the meals at the home and three answered ‘usually’. Residents spoken with at lunchtime all said that they were enjoying their lunch. In their AQAA, to demonstrate what the home does well, the manager stated that ‘The home seeks the views of the residents and considers their varied interests when planning the routines of daily living and arranging activities both in the home and the community. We have a monthly residents meeting in which all of the residents put forward their suggestions and ideas for the forthcoming months entertainment/ outings. Recent events have included a summer garden fete, for which resident gathered and made produce such as various jams, cookies, spicy olive oil, and hand painted place mats. Two recent canal boat trips down the River Wey and the Basingstoke canal were also a great success. Residents discuss menu suggestions, favourite foods and a suggestion is taken from each resident for an idea to implement in the home. The residents govern our menu also; we have a four weekly menu whereby the residents do not have the same meal twice in this period. We always offer alternatives to our main meal and our suppers. These are clearly displayed on the menu board in the dining room. A laptop is available for all residents use in private or with assistance. This has wireless connection to the internet (at no extra cost) enabling residents to have access to a wealth of knowledge or to communicate with families via e-mail.’ Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. Policies and procedures are in place to protect residents from potential harm or abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all residents and their relatives and is also included in the service users’ guide. No complainant has contacted the Commission with information regarding a complaint or allegation made to the service since the last inspection. All residents surveyed said that they always knew who to talk to if they were not happy, with one resident adding that: ‘the staff are very helpful.’ There is a whistle blowing policy in place and the home have a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. Training in safeguarding adults is included in the home’s staff induction and staff spoken with were aware of the correct procedures to follow. In their AQAA, to demonstrate what the home does well, the manager stated that ‘The ethos of our home is that we welcome complaints and suggestions about the service, we use these positively and learn from them. Our complaints procedure is clearly displayed on the notice board. We carry out our advocacy procedure monthly whereby residents are given the opportunity to speak to an external source (Runnymede Help the Aged) with whom we are affiliated.’ Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 16 All residents spoken with said that they felt safe at the home with one resident adding ‘very’. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing maintenance and redecoration programme provides the residents with clean, pleasant and homely surroundings in which to live. EVIDENCE: Residents spoken with expressed their satisfaction with the accommodation provided at the home. Of the seven residents surveyed, six said that the home was always fresh and clean and one answered ‘usually’. In their AQAA, to demonstrate what the home does well, the manager stated that ‘We have found that when residents arrive and are settled in they are often quite shy or reluctant to ask for any aids or help even when prompted. For that reason we have found that after the first couple of days or within a week of residency we ask an external occupational therapist to come and have an informal chat and carry out a needs assessment, this has highlighted things Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 18 such as handles above the bath, mirrors too high or too low in the bathroom or the general room layout not suitable. Over the last 12 months we have enlarged 3 residents rooms making one, which was not, en-suite. We have replaced standard baths with walk in baths in seven rooms. We have had our stairways and first floor carpets replaced. We have had our kitchen totally removed and replaced. We have carried out numerous improvements including all first floor hallway doors being replaced with fire check doors and the ground floor doors are currently having intumescent strips fitted.’ The home was toured during this visit. The furniture and furnishings were seen to be of a good quality and personal bedrooms were all seen to be personalised to the individual resident’s wishes. The maintenance and redecoration programme for the home was seen to be ongoing. Since the last inspection there have been many improvements to the communal and individual areas of the home as described by the provider above. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meets residents’ needs. The home has a comprehensive staff recruitment and training programme which incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. EVIDENCE: The staff rota evidenced that staff are provided in sufficient numbers to meet the needs of the residents at the home. The morning (8am – 2pm) shift is covered by four care workers, three care workers cover the afternoon/evening shift (2pm – 9pm) and the night staff consists of one waking care worker and one sleeping on the premises and available if needed. Of the seven residents surveyed, six stated that staff are always available when needed and one answered ‘usually’. Of the fifteen care staff, twelve hold a National Vocational Qualification (NVQ) level 2 or above in care. The remaining three care staff are working towards their qualification. During this visit the files of two members of staff, recruited since the last inspection, were sampled. Both files were seen to contain all required documentation and enhanced Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) list checks had been obtained for both applicants. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 20 Staff induction is in line with the new, mandatory Skills for Care common induction standards and the inspector was advised that staff are supervised until they have completed their induction. Staff are booked on additional training and updates as the courses become available. From the training records seen, all staff receive training and/or updates in all mandatory safe working practice topics. In their AQAA, to demonstrate what the home does well, the manager stated that ‘We have a recruitment procedure that has been the subject of much improvement recently and puts the needs of people who use the service at its core. The recruitment of good quality carers is seen as integral to the delivery of an excellent care service. We are highly selective with recruitment, the right person for the job being more important to the filling of a vacancy. Current residents will be given the opportunity to meet with prospective staff and their views taken on board as part of the selection process. We prioritise training and facilitate staff members to undertake external qualifications beyond the basic requirements, for example several members of staff are now studying level 4 NVQ. In addition to this we have recently embarked upon a training programme whereby all staff are carrying out an in depth common induction standards training programme. We feel that agency or temporary staff do not deliver the same level of personal care as long term staff and for this reason we do not use agency staff.’ Of the seven residents surveyed, all said that the staff always listened and acted on what they said. Additional comments made included: ‘the staff are very good’ and ‘the staff are lovely here.’ Staff surveyed all confirmed that the provider had carried out checks such as CRB and references prior to their employment. All staff also replied that they had been given training that they felt was relevant to their role, helped them to meet and understand the individual needs of the residents and that the home kept them up to date with new ways of working. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the clear management approach at the home providing an open, positive and inclusive atmosphere. The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the residents. Policies and procedures are in place to protect residents’ financial interests. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of residents and staff. EVIDENCE: The manager and assistant manager have both achieved their Registered Manager’s Award. The management style is inclusive and the residents benefit from the ethos, leadership and clear management approach of the home. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 22 A total of six care staff questionnaires were returned to the inspector on the day of this visit. From observations made on the day and from comments made on the staff questionnaire it is clear that the home have a close and happy staff team. Staff comments on the survey forms returned included: ‘Greys is a warm welcoming home with great managers and staff’ and ‘all staff are very kind and friendly. Any problems we have are solved by the manager.’ The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the residents and their relatives. The inspector was advised that the home carry out regular resident and relative surveys, correlate the responses and then take action to address any issues that are raised. Policies and procedures are in place to protect residents’ financial interests. The manager stated that the home does not handle the financial affairs for any residents. All staff have received required safe working practice training and updates. Staff were observed to be following appropriate health and safety practices as they went about their work. Prior to this inspection, a review of the incident notifications received by CSCI identified that there were a small number of residents that had each fallen on more than one occasion. This was discussed with the manager. At present the home do not have a system in place to regularly monitor incident forms in order to identify any patterns that may be emerging, although in each case measures had been taken to try to reduce the risk of falls. The manager felt that a monitoring system was a good idea and stated that he will be implementing such a system from now on. In their AQAA, to demonstrate what the home does well, the manager stated that ‘The views of both people who use the service and staff are listened to, and valued. We have a monthly residents’ meeting in which all of the residents put forward their suggestions and ideas for the forthcoming months entertainment/outings. Minutes are documented and kept on file. Residents discuss menu suggestions, favourite foods and much more, and a suggestion is taken from each resident for an idea to implement in the home. We have been inspected by the fire officer, Health and Safety Executive and Environmental Health over the last 12 months and have adhered to all recommendations. We have updated numerous policies and procedures, which have been reviewed and updated in line with current thinking and practice.’ All interactions observed between the staff and residents were inclusive, caring and respectful. Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that staff relate their daily records more closely to the required actions set out in the residents’ care plans to evidence that residents receive the care they require in the manner they prefer. It is recommended that newly identified problems are added to the front section of the care plan to enable staff to quickly identify all areas of need and ensure consistency of care. It is recommended that the home explore and introduce more in depth risk assessments, especially for the reduction of falls and the use of bed rails. 2 OP7 3. OP8 Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Greys Residential Home Ltd DS0000065590.V356053.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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